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Intrapartal Complications Complications of the: Powers Passageway Passenger Placenta Complications of the Powers Dystocia Dysfunctional or uncoordinated uterine contractions that result in a prolongation of labor Normal labor curve Abnormal labor curve Dysfunctional Labor Hypertonic Hypotonic Phase of Labor Latent (< 4 cm) Active (> 4 cm) Symptoms ↑freq Risks Fetal Distress-early Infection, Exhaustion, in labor process Hemorrhage, Late fetal distress Treatment Rest Uterus Stimulate Uterus R/O CPD, Breech, etc. Medications Morphine, Stadol Pitocin & intensity of ↓ freq & intensity of contractions, pain contractions, ↓effectiveness No progress in labor Nursing Care Hypertonic Dystocia Hypotonic Dystocia •Bedrest •Sedation to promote relaxation and reduce pain •Careful monitoring of mother and fetus •Relaxation techniques •Pain management •LOTS OF ENCOURAGEMENT •Careful monitoring of mother and fetus •Offer warm shower •Relaxation techniques •Assist with AROM and careful monitoring of fetus •Prepare to start Oxytocin infusion •LOTS OF ENCOURAGEMENT Precipitous Labor < 3 hours; Rapid Dilatation and Decent Risks Mom: genital tract lacerations, abruptio placentae, postpartum hemorrhage Fetus: meconium-stained fluid, bruising, cerebral trauma Treatment—safe passage of fetus through perineal support, calm atmosphere, careful assessment postpartum of both mom and baby Treatment, if Hx of precipitous labor Induce w/SROM BE READY Preterm Labor (PTL) = < 37 weeks PTL is the #1 perinatal and neonatal problem in US. A major goal of Healthy People 2020 Reduce PTL rate in US to 7.6 % In 2011, 12.8 % of all babies were born preterm (all-time high ) Rate is INCREASING, not decreasing Maternal Causes Race, SES, Age, < High School Education Unmarried Smoking History of AB’s LBW/PTL Metabolic Disease Alcohol in excess UTI in 3rd Trimester Illicit Drugs eg. Cocaine, heroine DES Exposure Poor Nutrition Anemia Exposure to Toxins Low Wt. Gain in PG Domestic Abuse Infections PIH Short interpregnancy interval Hx of Heart Disease Type 1 or 2 Diabetes Other Factors Fetal Multiple gestation Macrosomia Polyhydramnios Early Engagement Fetal Distress Placental Previa Abruption Risks Mother If Placenta is cause severe hemorrhage and Shock Fetus RDS and other complications of prematurity Hypoxia if the problem is placental Symptoms Uterine Activity Cx q 10” for 1 hour w/ or w/o pain Cervical changes Discomfort Dilatation of >2cm Abdominal Cramping; w/ or w/o diarrhea Effacement of >80% Dull, low back pain Vaginal Discharge Painful menstrual-like cramps Thicker or thinner Suprapubic pain Sudden spotting or blood, brown or colorless discharge Urinary frequency ↑ amt.; malodorous SROM Pelvic pressure Treatment Bedrest Hydration Antibiotics(if evidence of infection) Analgesic May be used in conjunction with tocolytics Tocolytic drugs Magnesium Sulfate—MgSO4 (IV) Bolus of 4-6 Gms over 15-30 min, then 1-4 gm/hour till contractions stop. Maternal Mg serum level for effectiveness in tocolysis is 5.5-7.5mg/dL Follow all nursing care r/t MgSO4 discussed earlier Nifedipine (Procardia; Ca++ channel blocker) 10-20 mg PO; 20 mg q6 hr x 24 hrs; 20mg q8 hrs Because mechanism of action is different from betaadrenergic agonists, it might be used in conjunction with terbutaline or ritodrine. Tocolytic drugs cont’d. Indomethacin (Indocin)- used for short-term management of PTL especially if Beta adrenergic agonists failed. Best to use for <5-7 days. As a prostaglandin inhibitor, it helps to stop contractions and prevent release of Oxytocin. po or pr: 25-50 mg q6hr for 48hr. Discontinue if birth is imminent or likely to occur within 24hr. Tocolytic drugs cont’d 17 Alpha-Hydroxyprogesterone Caproate Used only with single gestation pregnancies Acts to relax smooth muscle ie pregnant uterus Administered to prevent PTL Used for long-term management of PTL administered weekly (17 P) IM injection given z-track slowly over 35 min, to minimize discomfort best to ice the injection site prior to administration Side Effects & Complications of Magnesium Sulfate Magnesium Sulfate SIDE EFFECTS~Mom: flushing, drowsiness, muscle weakness, blurred vision, N& V COMPLICATIONS~Mom: pulmonary edema, respiratory depression or arrest, cardiac arrest, profound hypotension, hyporeflexia COMPLICATIONS Neonate: hypermagnesemia Side Effects & Complications of Calcium Channel Blockers SIDE EFFECTS~ MOM: flushing, tachycardia COMPLICATIONS~MOM: profound hypotension, possible decrease in uteroplacental perfusion Side Effects & Complications of Prostaglandin Inhibitors~ Indomethacin SIDE EFFECTS~ MOM: epigastric pain, nausea & vomiting COMPLICATIONS~MOM: GI bleeding, renal failure COMPLICATIONS Neonate: premature closure of the ductus arteriosus, necrotizing enterocolitis, intracranial hemorrhage Tocolytics: Beta2 Adrenergic Agonists Terbutaline/Brethine SQ .25 mg q 20-30” for 2 hrs .25 mg q 3-4 hrs SQ Pump 0.03-.01 mg/hr Max = 3 mg/24 hr PO 2.5 – 5.0 mg Q 4-6 hrs Tocolytics: Beta2 Adrenergic Agonists Lots of SIDE EFFECTS Maternal SOB, tachypnea, pulmonary edema Chest pain, ↓ B/P, Palpitations Fluid retention, ↓ Urine Tremors, Muscle cramps, H/A Hyperglycemia, hypokalemia, hypocalcemia, metabolic acidosis N/V Fetal Tachycardia Hyperinsulinemia Hyperglycemia (Fetus) Hypoglycemia (Neonate) Hyperbilirubinemia Hypotension Nursing Care w/Tocolytics Monitor IV rates CAREFULLY Continuous EFM—record q 15 minutes If FHR> 180 bpm, STOP beta adrenergic agonists Call MD Maternal VS and Cxs; record q 15” until stable then q 30” Notify MD if P > 120, STOP meds if: P > 120, > 6 PVC’s/min, systolic > 180, diastolic < 40, c/o chest pain, SOB Nursing Care w/Tocolytics Strict I& O Bedrest—Left Lateral Lung sounds---Pulmonary edema Daily Weights Urine for Glucose Serum Electrolytes EMOTIONAL SUPPORT PTL—Home Therapy Timing of taking oral medications Palpate contractions No heavy lifting, nipple stimulation, intercourse Quit work—take LOA May have uterine home monitoring Teach symptoms of PTL early in pregnancy Premature Rupture of Preterm PROM—rupture before 37 weeks Membranes gestation Diagnosis Nitrazine paper, pH strip- color change?? Fern test Risks Maternal: Chorioamnionitis/endometritis Fetal: PTL/Prematurity Stress of PROM may stimulate surfactant production and thus ↓ incidence of RDS Treatment of preterm PROM If infection noted Deliver If w/o infection; conservative mgmt VS q 4 especially noting elevated temp CBC, vaginal culture on admission Frequent BPP—assess amt of amniotic fluid Assess for uterine tenderness, any vaginal leaking Prophylactic antibiotics for 48 hrs often given Modified bedrest (NO WORK) NOTHING in Vagina; No Intercourse or tub bath Treatments Corticosteroids stimulates surfactant production, risk of NEC, & IVH in Fetus Betamethasone (Celestone) = 12 mg IM x 2 doses 24 hours apart Wait 1 week and repeat Dexamethasone (Decadron) = 6 mg IM X 4 doses 12 hours apart Fetal Kick Counts Choose time of day to sit quietly Count to 10 If < 10 movements in 12 hrs Call MD After meals, Count 4 movements If < 4 movements in 2 hrs Call MD Complications of the Passageway Cephalopelvic Disproportion (CPD) Risks Uterine Rupture Assisted Delivery cervical/vaginal lacerations Trauma to fetal head, Fracture, CNS damage Treatment Cesarean Section Complications of the Passenger Malpresentation Tranverse Lie Breech Brow/Face Multiple Gestation IUFD Fetal Distress Shoulder Dystocia Multiple Gestation (Twins +) Increase risk of PTL, Malpresentation, PIH, Maternal Hemorrhage ↑ incidence d/t fertility treatments Most common is twins 1/85 births is a twin Twins Monozygotic—33% of all twins 1 egg + 1 sperm= “Identical” Variations 2 amnions/2 chorions 30% (Dichorionic/diamniotic) 2 amnions & 1 chorion—68% (monochorionic/diamniotic) 1 amnion & 1 chorion –2% (monochorionic/monoamniotic) MOST COMPLICATIONS Twin-to-twin transfusion Dizygotic— 67% of all twins 2 eggs = 2 sperm = “Fraternal” 2 ovums + 2 placentas = 2 babies Risk for Multiple Gestation Family HX Increased maternal age Increased parity Conceiving within 1 month of stopping OC Increased frequency of Coitus Risks Maternal PTL Cardiac stress Anemia PIH Fetal Congenital anomalies Monozygotic twin-to-twin tranfusion Polyhydramnios Polycythemic Placenta previa Anemic Dysfunctional Labor Abnormal Presentation Umbilical Cords intertwined Management Antepartum U/S early to confirm twins > # of office visits ↑ caloric needs—see dietician ↑ rest Assess for infection Monitor fetal status U/S, NST’s, BPP Intrapartum Monitor twins 1 tocotransducter 2 U/S transducers or 1 U/S transducer and 1 scalp electrode Maternal VS, IV’s Vag delivery with C/Sec back up 2 OB’s/Peds/RN’s May have 1 baby vaginally and 1 baby by C/Section Management Postpartum Assess CLOSELY for Uterine Atony Emotional Support Support with Breastfeeding If Triplets or Quads or +++ C/Section is delivery method of choice Referrals to social worker/PHN Morgan, Sam, & Ben Shoulder Dystocia-an obstetrical emergency An intrapartum event that occurs when the infant’s head has been delivered, but the shoulders remain wedged behind the mother’s pubic bone Risk factors Macrosomic babies are most at risk GDM, Obesity, hx of previous LGA baby or previous shoulder dystocia Shoulder dystocia may occur when the woman has no risk factors. Management Position in McRobert’s position Legs and thighs flexed up to her abdomen with the head of the bed lowered Apply suprapubic pressure Apply pressure directly over they symphysis pubis to aid in dislodging the fetal shoulder Complications of Shoulder Dystocia Permanent injury to baby Brachial plexus injury (caused by excessive traction on fetal head) Fractured clavicles Asphyxia Neurologic damage Maternal Complications Heavy bleeding after delivery Tearing of the uterus, vagina, cervix or rectum Bruising of the bladder Other Fetal Complications IUFD—Intrauterine Fetal Demise Often detected by absent fetal movement Nursing Dx: Grieving, Altered family processes, Ineffective individual coping Goal: a supportive, pain-free delivery with resources available to make this a special memory for the family Cause is often unknown or there is some physiological maladaptation such as placenta previa/abruptio, maternal diabetes, or severe renal disease, profound congenital anomalies. Risks to mother -- prolonged retention of dead fetus can lead to DIC Diagnosis is based on absence of fetal heart tones and/or ultrasound Usually labor will begin on its own, if not, labor will be induced within 2 weeks of documented demise During labor, the woman is often sedated and an epidural is initiated soon after the onset of contractions so that labor is made as painless as possible. The couple may or may not wish to see the baby at that time, some may want to hold their baby. Treat them with respect. If the parents do not wish to see the baby, the baby should be baptized (if parents are Catholic), pictures taken, identification bands made out, foot prints taken, a lock of hair cut, and a weight and length recorded. This information is given to the family in a sealed envelope for them to open whenever they wish. If parents wish to hold the baby, give them some privacy and be near to answer any questions. Post-partally, offer the parents to be transferred off the maternity unit, and allow the father to stay as much as possible. Call pastor, priest, or rabbi for support. Refer to support groups, such as Resolve, Share, or Compassionate Friends. Studies have shown that parental grief after a stillbirth is aided if the parents name the baby, see the baby, hold the baby, and bury the baby. BE COMPASSIONATE, IT IS OKAY TO CRY WITH THE FAMILY. TRY TO FORGET YOUR OWN DISCOMFORT IN ORDER FOR THE FAMILY TO EXPRESS THEIRS. Complications of the Placenta Placenta Previa Placenta Abruptio Placenta Accreta Umbilical Cord Prolapse Placenta Previa Types Low Implantation Partial Previa Complete Previa PAINLESS VAGINAL BLEEDING in the 2nd3rd Trimester Dx Ultrasound Management Hospitalized, Bedrest Tocolysis, if contracting C/Sec NO VAGINAL EXAMS Placenta Abruptio Types Covert/Concealed Overt/Partial Overt/Complete Symptoms Knife-like pain w/concealed Shock Varying amt. of bleeding DX Fetal Distress U/S or CAT Scan Treatment Emergency C/Sec Placenta Accreta Placenta adheres to uterine myometrium It attaches itself too deeply into the lining of the uterus Maternal hemorrhage is often severe Does not respond to treatment for P/P hemorrhage Often results in hysterectomy Umbilical Cord Prolapse Extremely critical obstetrical situation Cord protudes from cervix into vagina Seen in breech and when presenting part is unengaged Position Mom Knee-chest, Trendelenburg, elevate hips Sterile gloved hand—hold presenting part off cord EMERGENCY C/SECTION, O2, ↑IV flow rate Other Complication Amniotic Fluid Embolism Pathophysiology Amniotic fluid enters maternal circulation→ pulmonary capillaries Tiny emboli form → pulmonary vasospasm →Hypoxemia and Acute Right-sided Heart Failure Symptoms Restlessness Chills Pallor Vernix and Lanugo ↓ B/P, ↑Pulse, ↑ Resp. DIC may develop Dyspnea Chest Pain Amniotic Fluid Embolism Medical Management Drugs Morphine Nursing Follow orders Semi-fowler’s position Oxygen Medication Aminophyllie Blood Products Digoxin I & O Cortisone If undelivered C/Sec STAY WITH MOTHER if suspect AFE Nurses must be alert to symptoms of what can go wrong and take initial steps to enhance the health of the mother and the baby.
